| NPI | 1568085264 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 2901600466) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901600466) |
| Enumeration Date | 2020-05-28 |
| Last Update Date | 2022-04-27 |